Provider Demographics
NPI:1700258340
Name:SAMUEL, SUSAN ELIZABETH (RDN, LD, IBCLC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:RDN, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31ST MEDICAL GROUP
Mailing Address - Street 2:UNIT 6180
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09604-6180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP
Practice Address - Street 2:UNIT 6180
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604-6180
Practice Address - Country:US
Practice Address - Phone:314-632-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-107478174N00000X
TXDT83995133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN